Endovascular treatment of direct carotid cavernous fistula resulting from rupture of intracavernous carotid aneurysm: A case report

BACKGROUND Direct carotid cavernous fistulas(CCFs)are typically the result of a severe traumatic brain injury.High-flow arteriovenous shunts secondary to rupture of an intracavernous aneurysm,resulting in direct CCFs,are rare.The use of a pipeline embolization device in conjunction with coils and Onyx glue for treatment of direct high-flow CCF resulting from ruptured cavernous carotid artery aneurysm in a clinical setting is not well documented.CASE SUMMARY A 58-year-old woman presented to our department with symptoms of blepharoptosis and intracranial bruits for 1 wk.During physical examination,there was right eye exophthalmos and ocular motor palsy.The rest of the neurological examination was clear.Notably,the patient had no history of head injury.The patient was treated with a pipeline embolization device in the ipsilateral internal carotid artery across the fistula.Coils and Onyx were placed through the femoral venous route,followed by placement of the pipeline embolization device with assistance from a balloon-coiling technique.No intraoperative or perioperative complications occurred.Preoperative symptoms of bulbar hyperemia and bruits subsided immediately after the operation.CONCLUSION Pipeline embolization device in conjunction with coiling and Onyx may be a safe and effective approach for direct CCFs.

Endovascular procedure-related spontaneous closure of traumatic carotid cavernous fistula: case report

Objective BACKGROUND Spontaneous closure of direct traumatic carotid cavernous fistulas (TCCFs) is rare. A few cases have been reported in literature to be related to diagnostic cerebral angiography and orbital venography. Several mechanisms have been postulated, including irritation of the vessels from contrast media, compression of the carotid artery and reduced blood pressure from general anesthesia. In our own series of about 400 patients at Ramathibodi Hospital, the incidence is approximately 1.75%.CASE PRESENTATION We present a case, which spontaneous closure occurred during attempted endovascular embolization. A 45-year-old woman with left TCCF was referred to our hospital for endovascular treatment. Cerebral angiogram revealed a small-hole fistula at the posterosuperior wall of C2-3 segment of the LICA. Transarterial balloon failed due to the small size of the fistula and acute retroangulation of the balloon attached microcatheter. Transarterial GDC coil placement into the first venous pouch was then attempted for two times, but was unsuccessful. During repositioning of the microcatheter for a third attempt, spontaneous closure of the fistula was observed and confirmed by control angiogram. CONCLUSION Spontaneous closure of direct traumatic carotid cavernous fistulas may occur during endovascular procedures, which can be caused by dissection of the venous pouch by the microcatheter or coils during manipulation, irritation of the vascular walls from the contrast media and decreased blood pressure from general anesthesia.

Endovascular treatment of carotid cavernous sinus fistula: A systematic review

Carotid cavernous sinus fistulas are abnormal communications between the carotid system and the cavernous sinus. Several classification schemes have described carotid cavernous sinus fistulas according to etiology, hemodynamic features, or the angiographic arterial architecture. Increased pressure within the cavernous sinus appears to be the main factor in pathophysiology. The clinical features are related to size, exact location, and duration of the fistula, adequacy and route of venous drainage and the presence of arterial/venous collaterals. Noninvasive imaging (computed tomography, magnetic resonance, computed tomography angiography, magnetic resonance angiography, Doppler) is often used in the initial workup of a possible carotid cavernous sinus fistulas. Cerebral angiography is the gold standard for the definitive diagnosis, classification, and planning of treatment for these lesions. The endovascular approach has evolved as the mainstay therapy for definitive treatment in situations including clinical emergencies. Conservative treatment, surgery and radiosurgery constitute other management options for these lesions.

Color Doppler Imaging in the Diagnosis and Follow-up of Carotid Cavernous Sinus Fistulas

This report describes color doppler imaging (CDI) in theevaluation and follow-up of nine patients with carotid cavernous sinusfistulas.The orbits and carotid arteries were examined with CDI.In allcases,the diagnosis was confirmed by angiography.CDI clearlydemonstrated the dilated superior ophthalmic veins (SOVs) with retrogradeflow and low resistance arterial doppler waveform in all nine patients (10eyes).After the study of quantitative hemodynamics,we found that directcarotid cavernous sinus fistulas s...

Endovascular management of carotid-cavernous fistulas

Objective To investigate endovascular treatment of traumatic direct carotid-cavernous fistulas (CCF) and their complications such as pseudoaneurysms. Methods: Over a five-year period, 22 patients with traumatic direct CCFs were treated endovascularly in our institution. Thirteen patients were treated once with the result of CCF occluded, 8 twice and 1 three times. Treatment modalities included balloon occlusion of the CCF, sacrifice of the ipsilateral internal carotid artery with detachable balloon, coil embolization of the cavernous sinus and secondary pseudoaneurysms, and covered-stent management of the pseudoaneurysms. Results All the direct CCFs were successfully managed endovascularly. Four patients developed a pseudoaneurysm after the occlusion of the CCF with an incidence of pseudoaneurysm formation of 18.2% (4/22). A total number of 8 patients experienced permanent occlusion of the ICA with a rate of ICA occlusion reaching 36.4% (8/22). Followed up through telephone consultation from 6 months to 5 years, all did well with no recurrence of CCF symptoms and signs. Conclusion Traumatic direct CCFs can be successfully managed with endovascular means. The pseudoaneurysms secondary to the occlusion of the CCFs can be occluded with stent-assisted coiling and implantation of covered stents.

Transvenous Embolization of Carotid Cavernous Fistula by Sequential Occlusion of the Cavernous Sinus

Objective Introduction When we perform transvenous embolization of carotid cavernous fistula, we selectively occluded the venous outflow to the retrograde cortical venous drainage and retrograde ophthalmic venous drainage as the initial steps before the rest of the cavernous sinus. The rationale is to prevent re-diversion of flow into the ophthalmic veins and cortical veins in a subtotally occluded carotid cavernous fistula.Method From 1997 to 2004, a total of 46 patients with carotid cavernous fistula were treated by transvenous embolization using the proposed selective occlusion strategy. There were 6 direct and 40 dural cartoid cavernous fistulae. The embolic agents were Guglielmi detachable coils and fibered platinum coils. Transvenous embolization routes included inferior petrosal sinus (IPS) alone (32 patients), IPS and intercavernous sinus (9 patients), and superior ophthalmic vein (5 patients).Result The follow-up period ranged from 4 months to 7 years. One patient developed retinal hemorrhage due to ophthalic vein thrombosis one week after the embolization procedure. Two patients had transient ophthalmoplegia and 2 patients had symptomatic recurrence of the carotid cavernous fistula during the follow-up. Clinical cure was achieved in 44 patients (96%).Conclusion The sequential occlusion strategy offers a safe and effective method in the transvenous embolization of carotid cavernous fistula.

Endovascular treatment of traumatic direct carotid cavernous fistulas with n-Butyl-2-Cyanoacrylate

Objective To explore the method and safety of endovascular treatment of traumatic direct carotid cavernous fistulas with n-Butyl-2-Cyanoacrylate. Method A total of 11 patients with traumatic direct carotid cavernous fistulas treated by endovascular embolization with n-Butyl-2-Cyanoacrylate. (n-BCA) were retrospectively analyzed,including the

Management of traumatic carotid-cavernous fistula

Sixty-eight patients with traumatic carotid-cavemous fistula (TCCF) were treated by intravascular embolization. All patients were cured and 94.1% of internal carotid arteries were preserved. Proptosis, bruit and chemosis disappeared following embolization. The diagnosis and management of TCCF are also evaluated.

Diagnosis and endovascular treatment of spontaneous direct carotid-cavernous fistula

Background Spontaneous direct carotid-cavernous fistula （CCF） is relatively rare and few reports have been found in the literature. The aim of this paper was to report the clinical characteristics, imaging findings and curative effect of endovascular treatment for patients with spontaneous direct CCF. Methods We retrospectively analyzed the clinical data of nine patients with spontaneous direct CCF admitted between May 2003 and November 2007 and the outcomes.of endovascular treatment. Sudden neuro-ophthalmological symptoms were the most common clinical presentation at diagnosis （n=8）. No patients had a history of head trauma. Cerebral digital subtraction angiography （DSA） was performed on all cases under local anesthesia and seven cases received endovascular treatment. Results In eight patients, internal carotid angiograms recorded during the early arterial phase revealed aneurysms located in the cavernous sinuses, and in one patient, a dilated internal carotid artery （ICA） was seen. Among the nine cases, seven received endovascular treatment via a transarterial approach and complete occlusion of the fistula was obtained with no technique-related complications, one died suddenly before treatment and one gave up treatment. A detachable balloon was used as the embolic material in two cases, a detachable balloon and detachable coil as the embolic material in two cases, balloon-assisted coil embolization in two cases and covered stents were successfully placed in the parent vessel to exclude the aneurysm and fistula from circulation in one case. During a follow-up period of 3-48 months, all treated patients remained asymptomatic except for one patient who suffered from ipsilateral decreased vision. Conclusions Most spontaneous direct CCF may be caused by a ruptured intracavernous aneurysm with direct shunting into the cavernous sinus. Endovascular treatment seems to be a safe and effective method for treating spontaneous direct CCF.

Management of Carotid Carvenous Fistula in Ghana;Challenges and Opportunities

Carotid-cavernous fistula is an abnormal communication between the carotid artery and the cavernous sinus. The fistula is classified based on its etiology, haemodynamic and anatomical configuration. The most common type is the direct high flow fistula resulting from trauma. Indirect fistula which is less common results from underlying conditions such as hypertension, collagen vascular diseases, pregnancy amongst others. It is in regards with this uncommon occurrence of indirect fistula that we report a case of forty years old woman who presented with a left protruding eyeball and headache a month after delivery and was diagnosed with spontaneous type D indirect carotid cavernous fistula with rapidly progressing symptoms. She was referred abroad for interventional radiological services due to unavailability of such services in our facility and country.

Transvenous treatment of a complex cavernous sinus dural arteriovenous fistula secondary to balloon embolization of a traumatic carotid-cavernous fistula

Although recurrent traumatic carotid-cavernous fistula （CCF） and its treatment have beenreported sporadically,^1 a complex cavernous sinus dural arteriovenous fistula （DAVF） secondary to balloon embolization of a direct traumatic CCF is rare. In 2005, we treated such a case via transvenous approach using coils and N-buty-2- cyanoacrylate （NBCA）. The causes of recurrent cavernous sinus DAVF and its endovascular approach are discussed.

Classification and digital subtraction angiography evaluation of carotidcavernous fistulas

Objective To investigate the role of digital subtraction angiography (DSA) in evaluation of carotid cavernous fistulas, and to initiate a new classification for carotid cavernous fistula Methods Cerebral angiography and selective external and internal carotid angiography were carried out in 56 patients who were classified into 5 types according to their hemodynamic features Results The types were A (38 patients), B (4), C (10), D (2), and E (2) One of the 38 direct fistulas was located at C1 of the cavernous segment Fistulas at C2 were observed in 10 patients, at C3 in 4, at C4 in 10 and at C5 in 5 The anterior communicating arteries were patent and well compensated in 33 of the 56 patients The posterior communicating arteries were patent and well compensated in 39 patients Both communicating arteries were well compensated in 31 patients Fifty of the 56 patients were drained by ophthalmic veins, 47 by inferior petrous sinuses, 18 by cortical veins, and 8 to the posterior fossa region Conclusions Digital subtraction angiography was helpful in localization of the rents in carotid cavernous fistulas, in evaluation of function of Willis circles and provided valuable information for treatment of carotid cavernous fistulas Carotid cavernous fistulas were divided into 5 categories: type A, B, C, D and E, among which type E was not previously described elsewhere

Bilateral carotid cavernous fistula after trauma:a case report and literature review

Background:Carotid cavernous fistula is a rare complication that is typically associated with head trauma and skull base fractures.The traumatic bilateral carotid cavernous fistula are significantly rarer.Case presentations:We report a case of a 61-year-old man presenting with unilateral exophthalmos,swollen eyelids,conjunctival congestion,and edema etiologically associated with severe trauma.Thereafter,the patient demonstrated symptoms of contralateral oculomotor nerve injury caused by skull base fracture,such as ptosis of eyelid,dilated pupils,and eye movement disorder,and was diagnosed with bilateral carotid cavernous fistula.Conclusions:The patient recovered after undergoing endovascular embolization of bilateral cavernous sinus fistulas.The patient demonstrated the classic symptoms of an extremely rare condition known as bilateral carotid cavernous fistula,in only one eye.Reporting and analyzing this case will help us elucidate the underlying mechanisms of this disease.

Endovascular treatment of a giant internal carotid artery bifurcation aneurysm with drainage into cavernous sinus

This report documents the treatment of a giant aneurysm of the internal carotid artery bifurcation with a fistula to the cavernous sinus, which appeared following closed head trauma. A 39-year-old man suffered from a blunt head trauma in an automobile accident. Two weeks after the trauma, progressive chemosis of left eye was presented. Four months after the trauma, digital subtraction angiography showed an internal carotid artery bifurcation aneurysm, with drainage into the cavernous sinus. The lesion was successfully obliterated with preservation of the parent artery by using coils in conjunction with Onyx. Follow-up angiography obtained 3 months postoperatively revealed persistent obliteration of the aneurysm and fistula as well as patency of the parent artery. Endovascular treatment involving the use of coils combined with Onyx anneam to be a feasible and effective o[}tion for treatment of this hard-to-treat lesion.

颈动脉海绵状瘘的眼科表现及研究进展

颈动脉海绵窦瘘通常以眼部症状为首发临床表现,由于其表型多变,患者常被误诊为其他眼部疾病,极易漏诊误诊,导致治疗延误,因此我们通过对颈动脉海绵窦瘘进行文献综述,有助于了解颈动脉海绵窦瘘的眼部特征、分类诊断、可能的治疗模式和预期结果。

眼眶病1例

20岁男性患者,因交通事故后右眼眶骨折入院。患者门诊首诊时无颈动脉海绵窦瘘相关症状及体征,伤后2个月检查发现右眼眼压升高,伴有结膜血管扩张。脑磁共振血管成像(MRA)证明为右侧创伤性颈动脉海绵窦瘘,动脉造影证实了这一点,患者对栓塞治疗反应良好。讨论体会:该病例的临床意义在于临床诊疗过程中必须重视基本的体格检查,创伤后高眼压需系统分析其可能的因素,并且在外伤后数月,也应该考虑创伤性颈动脉海绵窦瘘存在的可能性。

超声诊断技术在神经眼科疾病中的应用

眼科超声诊断设备包括常规B超、高频B超、超声生物显微镜以及彩色多普勒超声,对各种眼科疾病的诊断及鉴别诊断具有重要意义。随着超声诊断水平的进步,尤其是高频B超和彩色多普勒超声在眼科的应用发展,推动了视盘水肿、颅内压增高、颈动脉海绵窦瘘、眼缺血综合征以及巨细胞动脉炎等多种复杂神经眼科疾病诊断的进步。

外伤性颈动脉海绵窦瘘伴颅内出血急诊血管内介入治疗

目的 探讨表现为颅内出血(ICH)的外伤性颈动脉海绵窦瘘(CCF)的临床特点和急诊血管内介入治疗方式。方法 回顾性分析2010年1月—2017年4月苏州大学附属第二医院收治的5例表现为ICH的CCF患者的临床资料,均有明确的头部创伤史,并经头部计算机断层扫描确认为ICH。所有病例均经数字减影血管造影确诊为颈动脉海绵窦瘘,并行急诊血管内介入治疗。所有患者门诊随访,评估临床预后。结果 5例患者均为单侧颈动脉海绵窦瘘,2例采用可脱性球囊栓塞,2例采用可脱性弹簧圈栓塞,1例采用Onyx胶联合可脱性弹簧圈栓塞。1例经二次可脱性球囊栓塞治愈,另4例均一次性治愈。所有患者随访3~10年,均未再发生ICH及症状复发;1例颈内动脉迟发性闭塞,其余均获得保留。结论 表现为ICH的颈动脉海绵窦瘘临床过程急重,需急诊行血管内介入治疗;根据病灶的不同特点个体化地选择相应的治疗措施是安全、有效的。

介入栓塞治疗外伤性颈动脉海绵窦瘘的疗效

目的 探讨介入栓塞治疗外伤性颈动脉海绵窦瘘(TCCF)的临床疗效及影像学变化。方法 选取77例TCCF患者的临床资料,按照不同的手术治疗方法分为球囊辅助弹簧圈栓塞(球囊辅助组35例)、可脱性球囊栓塞(可脱性球囊组38例)、Willis覆膜支架栓塞(覆膜支架组4例),分析栓塞术后的影像学表现和预后。结果 77例患者共计手术84台次,行一次栓塞治疗70例,两次栓塞治疗7例。总体治愈率100%,颈内动脉通畅率97.4%。球囊辅助组与可脱性球囊组相比完全闭塞率、手术并发症发生率、一次性栓塞治愈率无明显差异。所有患者随访显示疗效可靠。结论 球囊辅助弹簧圈和可脱性球囊栓塞方法可作为治疗TCCF的首选方案,安全可靠。